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5 NURSE WAY - BUILDING INSPECTION (004) n , \' Commonwealth of lMassat husetts Sheet Metal Permit F;tiniated Job Cost: S._-�T5a Permit Fee: S �7/ Plans Submitted: YES NO Plans Reviewed: YES NO Business License #-DL-k 3HS60 L&- Applicant License 1# 01� Business 1116ormation: Property Owner/Job Location Information: Name: Q C- Name: t wt rr�it , Q�22t�lo U k±6' t LL, Street: Street:t _ 1ZS12 City/Town: i,) t Py,,t rnr`t� (� City/Town: �w�_ Telephone: 9,)s 65 l [ ( Telephone: C-D e •"7-14&� Photo I.D. required/ Copy of Photo I.D. attached: YES P's, NO srarrrndn,r J-1 /9nurstricted license J-2/ M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. It. / 2-stories or less Residential: 1-2tamily�-. Multi-family_ Condo/'fownhouses_ Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. 7� over 10,000 sq. tt. _ Number of Stories: Street metal work to he completed: New Work: _ Renovation: I[VAC� Metal Watershed Roofing _ Kitchen Exhaust System Metal Chimney/ Vents_ Air Balancing _ Pt'M idc detailCd description of work to be done: f�rdt- PvtlNrace wcYE Cam' TA INSURANCE COVERAGE: I have a current liabilityInsurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes J No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: '" t ❑ A liability Insurance policy fL�`S, Other type of indemnity Bond ❑ OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By checking this box0,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and ons Performed under the prmit In complianceewbest of my knowlede and that ithal pertinent provision of all shoot metal work and Building Cods aind Chapter12 of the Generued for this application will be al Laws. Duct Inspection required prior to insulation Installation: YES_NO Prorrress Insacctions Date Continents Final Inspection Data Conlnlents Type of License: By taster oue ._ ❑ %taster-Restricted o:•:n .________— ❑Journeyperson Signature of Licensee t'•'nn'I a ----- ❑Journeyperson-Restricted t"l�9 License Number. i Roe i - --- - - -----— -- ❑ -------- _Check at ovhlLl i I i Inspector Signature of Permit Approval COMMONWEALTH OF MASSACHUSETTS ce •. -• • :•. •rr BOARD SHEET METAL WORKERS SM AS A MASTER-UNRESTRICTED --%,.=TO TYPE ER''IK M TIMMONS _ M1 I6R PINEWOOD RE) WILMINGTON MA 01887- 1930 48731 429 09/28/13 48731 • rmm Jt�ASSAG6�IUSETm 4, , DWM'S'LMENSE �57"a27836 � 09.26-2013 09.26-1sa 9fi$° WIVIONS M ERIKM f #- t6S PDEW00D RD _ WILMMOTON,IM x i a CITY OF S:U.ENls ANSSACHUSETTS BUILDING DEPARTN(ENT 120 W.\SHLYGTON STREET, 3iO FLOOR T EL. (978) 745-9595 F.A.e(978) 740-9844 ICI.,[B Rt EEY DRISCOLL THOhIASST.PUMS MAYOR DIRECTOR OF PUBLIC PROPERTYIBCMDCIG CONNISSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electrictans/Plumbers Amilleant Information Please Print Legibly V:llnc tousitx.ss,Organiratiarvindividual): Address: Lk City/State/Zip: w_.KRln 04- 7-'(40� '7 Phone M: o/ -7 Z Are ou an employer?Check the appropriate boar 'type of project(required): 1 m a employer with ('0 4. 0 1 am a general contractor and 1 6, ew construction employees(Nit and/or part-time).* have hired the subcontractors 2.0 1 atn a sole proprietor air partner- listed on the attached sheet t �• ❑Remodeling ship and have no employees, These subcontractors have a. ❑Demolition working for me in any capacity. workers'camp.insurance. 9, 0 Building addition (No workers comp.insurance I 5. 0 we are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.)t employees.Net workers' 13.0 Other, camp.insurance required.] •Any applle:ml ttwt ehmks box I I mutt atw all uul the s i floo MOW thawing thek wakens'mmpensmiun pulley inilamro ion 'I h"inawtwis who submit this affidavit indicating they am doing ell work and that him outsidecontractan must submit a new allfdavit indicating tuck =Comtnotan that chc<k ibis box most onuhod an addidunal that showing the name of the suNeetnncton and thak wurkam,ramp.policy Inromtaden, r am an euployer that Is provldlnA Ivorken'compauadon hrruranee for my etnplayera Below is the poltey and fob site irrfor»rallon. Insurance Company Name: Policy 4 or Sdf•ivs. Lie. it: Expiration Dote: Job Site Address: City/State/zip. ,\Mach a copy of the workers,compensation policy declaration page(showing the policy number and iapirailon date). F`allura to secure coverage as required under Section 25A of VIOL c. 152 can lead to the imposition of criminal penalties of a ring up to S1,500.00 and/or one-year imprisonment as well as civil penalties in the form of STOP WORK ORDER and a line of up to S230.00 a day against the violator. Ile advised that a copy of this statement may be rurwardcd to the Office of Investigadons of the DIA for insurance coverage verification. 1,10 hors, c f y t rddr Nrr pains uad penoldet ofperfury that the hefarrnurfms provided above it true and correct. ' Phone i• tljjic ial rise anly. Do our write in this area, to be conspieled by city ut town n/Jletu! i CiryotTuwn: .... --Per mit/lAcense � I.uuing Aulliorily (circle one): I. Board of Ilealth Z. Building Departnwat .I.caytruwn Clerk 4. rleetrical f ispcetur 5. Plumbing inspector i i 6.Other Gnstad I'crsnn: Phona Ile 4/16/2013 9:41 AM FROM: North Andover INS M.J. Foster Insurance Services, Inc. PAGE: 002 OF 003 ACII CERTIFICATE OF LIABILITY INSURANCE OATE IMMDB,YYYQ 04/16/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT HOVE: NORTH ANDOVER INSURANCE AGENCY, INC. PHO(AM,N NO, EX: (978) 686-2266 �nm Nq:(936) ses-solo M.T. FOSTER INSURANCE SERVICES ADoBESS, cfernandez@nafins.com 163 MAIN STREET CUSTOMER D n: B.J. Doyle, Inc. NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAICC INSURED INSURER A MERCRANTS INSURANCE GROUP 13775 B. J. Doyle, Inc. INSURER 8 4 Jeweel Drive INSURER G TT Unit 8 INEURER D IN BUR E Wilmington MA 01887- INSURER F '. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SVBR POLICY EFF POLICY ENP LT R TYPE OF INSURANCE NSR AND POLICY NUMBER (MxvooN Yyd (MNDDN YY( LHATS A GENERAL LIABILITY ][ NF9152831 0/23/2012 0/23/2013 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / PREMISES IEC occunence $ 100,000 CLAIMSWADE �X OCCUR / / / / RED EXP Any one person) $ 5,000 PERSONAL B ADV INJJRY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRD LUC A AUTOMOBILE UABLITY CA7015612 0/23/2012 0/23/2013 COMBINED SINGLE LIMIT $ 1,000,000 (Ed accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS / / / / / / / / BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE x HIREDALITGS / / / / (Pare'ederi $ X NON-OVNMEDAUTOS A X UMBRELLA UAB X OCCUR UP9144329 0/23/2012 O/23/2013 EACH OCCURRENCE $ 1,000,000 EXCESS UAB CLAIMS-MADE / / / / AGGREGATE $ 1,000,000 DEDUCTIBLE RETENTION $ A WORKERS COMPENSATION CA9098032 0/23/2012 O/23/2013 X LhC STAIN OTH- AND EMPLOYERS' LIVBILRY T ER ANY PROPddETOPRARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 L OFFICERAdEMBER EHCLODED9 ❑ NIA (Mandatary in NH) / / / / EL.DISEASE-EA EMPLOYE $ 500,000 It as describe under DESCRIPTION OF OPERATIONS below / / / / ELDISEASE-POLICY LIMIT 1$ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (i ACORD 101. AONUOINI Nei ssKi R ri s'Ae is rt4unM) RE; 215, 233 R 234 NURSE WAY, SALEM, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SALEM SALEM CITY HAUL AUTHORREO REPRESENTATIVE 93 WASHINGTON STREET s''`�~3 SALEM MA 01970- ACORD 25(2009109) ©1988.2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD 4/16/2013 9:41 AM FROM: NODth Andover INS M.J. FOetd, TrU.T.LG'e Se Tvices, Inc. PAGE: 003 OF 003 aco®• "F"I CERTIFICATE OF LIABILITY INSURANCE °A'/ �M° 04/16/2013013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. PHONE., Exl: (978) 666-2266 (978) 686-6410 I. AM, PAL 111Lcfernandez@nafins.com M.J. FOSTER INSURANCE SERVICES ADDREOREss: 163 MAIN STREET CUSTOMER ID x: B.J. Doyle, Inc. NORTH ANDOVER MA 01845-2508 INSURER(S)AFFORDING COVERAGE NAICC INSURED INSURER A MERCHANTS INSURANCE GROUP 13775 H. J. Doyle, Inc. INSURER B 4 JeWel DriT/e INSURER C Unit # 8 INSURER D INSURER E Wilmington MA 01887— INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO MICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AODL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INeR ME POLICY NUMBER (MNODMYYYI (NDOOIYYYY) LAWS A GENERAL LIABILITY Y[ MP9152831 0/23/2012 O/23/2013 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / / PREMISES EDCC0.ITY11 $ 100,000 CI-AIMS-MADE OCCUR / / / / RED EAP(ALLY one person) $ 5,000 PERSONAL B NEW ILI $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. / / / / PRODUCTS-COMPIOP ADS $ 2,000,000 X POLICY PRO JECT LOC / / / / $ A AUTOMOBILE LIABUTY ICA7015612 0/23/2012 0/23/2013 COMBINED SINGLE LIMIT $ 1,000.,000 MY AUTO / / / / (ED emident) / / / / BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY IPeracdtlenO $ X SCHEDULED AUTOS / PROPERTY OPMAGE X HIRED AUTOS / X NON-OWNED AUTOS 1 A X -BE— UAB NX OCCUR UP9144329 0/23/2012 0/23/2013 EACH OCCURRENCE $ 1,000,000 EXCESS LIAR CAMS-MADE / / / / AGGREGATE $ 1,000,000 DEDUCTIBLE RETENTION A WORKERS COMPENSATION UCA9098032 0/23/2012 0/23/2013 X KC STATU- OTH- AND EMPLOYERS' LIMBILTY 1,/N T ANY PROPRIETOWPARTNEPIEXECGnvE / / / / E.L.EACH ACCIDENT $ 500,000 0710ERMEMBER EXCLUDED? ❑ NIA (Mandator,in NH) / / / / EL.DISEASE-EA EMPLOYEE $ 500,000 Nye,desuibe under DESCRIPTION OF OPERATIONS below / / / / E L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Atttth ACORD '(n Ao IMdI R—A. e[Rxftn, P nicn, fpM! I. M'.) RE: 230, 231 fi 232 GOOD CIRCLE, SALEM, MA CERTIFICATE HOLDER CANCELLATION ( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CITY OF SALEM ,SALEM CITY HALL! AUTHORED REPRESENTATIVE 93 WASHINGTON STREET SALFM MA 01970- ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. I NS0251200909) The ACORD name and logo are registered marks of ACORD .I